Curettage plus one or two cycles of cryosurgery for basal cell carcinoma with clinically nodular features: A prospective randomized controlled trial
Authors: Eva Backman, Sam Polesie, Martin Gillstedt, Alexandra Sjöholm, Azad Nerwey, John Paoli
Journal: Journal of the American Academy of Dermatology (2023)

To the Editor: Cryosurgery has been a common destructive treatment for skin cancers since the 1960s, when modern liquid nitrogen spray-guns were introduced.1Copper I.S. Cryogenic surgery: a new method of destruction or extirpation of benign or malignant tissues.N Engl J Med. 1963; 268: 743-749Crossref PubMed Google Scholar,2Torre D. Cryosurgical treatment of epitheliomas using the cone-spray technique.J Dermatol Surg Oncol. 1977; 3: 432-436Crossref PubMed Scopus (27) Google Scholar Two cryosurgery sessions, with or without prior curettage, is recommended for nodular basal cell carcinoma (BCC).3Mallon E. Dawber R. Cryosurgery in the treatment of basal cell carcinoma. Assessment of one and two freeze-thaw cycle schedules.Dermatol Surg. 1996; 22: 854-858Crossref PubMed Scopus (77) Google Scholar Updated BCC guidelines highlight the lack of evidence for cryosurgery.4Work G. Invited R. Kim J.Y.S. et al.Guidelines of care for the management of basal cell carcinoma.J Am Acad Dermatol. 2018; 78: 540-559Abstract Full Text Full Text PDF PubMed Scopus (221) Google Scholar The primary objective of this study was to compare clearance rates after 1 year for curettage and cryosurgery in 1 (C&Cx1) versus 2 freeze-thaw cycles (C&Cx2) for nonfacial BCCs with clinically nodular features. The secondary objectives were to compare wound healing times and to evaluate patient satisfaction with the scars. Curettage (4- or 7-mm curette) was followed by cryosurgery (open-cone spray technique) aiming for a halo thaw time ≥60 s (otherwise repeated). In lesions randomized to C&Cx2, the second freeze was performed after complete thawing of the lesion (Supplementary Methods, available via Mendeley at https://doi.org/10.17632/x5h2skp4zz.1). Overall, 202 lesions in 116 patients (34% females) were included in the analysis (per protocol) (Fig 1). The median age was 72 years (range 31-88 years). The median lesion diameter was 10 mm (range, 5-20 mm). All BCCs diagnosed dermoscopically (n = 130) were confirmed histopathologically after treatment. The distribution of BCC subtypes was: 114 nodular, 54 infiltrative, 13 superficial, and 21 unspecified (Table I).Table IPatient and tumor characteristicsPatient characteristics at inclusionTotal (n = 116)Age at the initial treatment, years Median (range)72 (31-88)Sex Male76 (66%) Female40 (34%)Tumors per patient, n Mean (SD)1.7 (1.2) Median (range)1 (1-6)Smoking habits Smoker3 (3%) Former smoker35 (30%) Never smoked76 (66%) Missing data2 (2%)Immunosuppression Yes17 (15%) No99 (85%) Missing data0 (0%)Diabetes Yes12 (10%) No103 (89%) Missing data1 (1%)Tumor characteristicsC&Cx1C&Cx2TotalTumors, n (%)103 (51.0)99 (49.0)202 (100)Location, n (%) Neck6 (5.8)5 (5.1)11 (5.4) Trunk85 (82.5)71 (71.7)156 (77.2) Upper limbs8 (7.8)15 (15.2)23 (11.4) Thigh4 (3.9)8 (8.1)12 (5.9)Mean diameter in mm, (SD)10.2 (3.9)10.1 (4.1)10.1 (4.0) Range5-205-205-20Histopathologically verified lesions, n (%)103 (100)99 (100)202 (100)Histopathological subtype, n (%) Nodular59 (57.3)55 (55.6)114 (56.4) Infiltrative27 (26.2)27 (27.3)54 (26.7) Superficial6 (5.8)7 (7.1)13 (6.4) Unspecified growth pattern∗According to the pathology reports, curettage material or small biopsy size made subtyping unreliable.11 (10.7)10 (10.1)21 (10.4)C&Cx1, Curettage plus cryosurgery with 1 freeze-thaw cycle; C&Cx2, curettage plus cryosurgery with 2 freeze-thaw cycles; mm, millimeters; n, number; SD, standard deviation.∗ According to the pathology reports, curettage material or small biopsy size made subtyping unreliable. Open table in a new tab C&Cx1, Curettage plus cryosurgery with 1 freeze-thaw cycle; C&Cx2, curettage plus cryosurgery with 2 freeze-thaw cycles; mm, millimeters; n, number; SD, standard deviation. There were no significant differences regarding mean freeze time (18.6 s for cryox1 vs 17.7 s for cryox2, P = .087) nor mean halo thaw time (83.2 s vs 84.4 s, P = .60) during the first freeze-thaw cycle. At 1 year, a single recurrence was found in the C&Cx1 group resulting in clearance rates of 99% versus 100%, proving the non-inferiority hypothesis with an absolute difference <8% (Supplementary Fig, available via Mendeley at https://doi.org/10.17632/x5h2skp4zz.1). The mean time for oozing wounds was 1.0 (SD = 1.3) week for C&Cx1 and 1.2 (SD = 1.2) weeks for C&Cx2 (P = .062). After 4-6 weeks, 71% of the wounds had remaining crusts, 13% still had oozing, and 11% were completely healed without any significant differences between the 2 groups (Supplementary Table, available via Mendeley at https://doi.org/10.17632/x5h2skp4zz.1). Larger lesion size was the only relevant factor that significantly increased wound healing times (P = .0008) After 1 year, 105 patients reported satisfaction with their scars, 1 was unsatisfied and 4 felt neutral about the cosmesis (missing data for 6 patients). Overall, 9 treatment related adverse events were reported; 2 wound infections, 6 lesions with prolonged wound healing, and 1 report of itching 3 months after treatment. Study limitations include: single center investigation involving 5 physicians, only nonfacial lesions included and impossibility of blinding allocated treatment. Also, clearance was assessed by dermoscopic evaluation and lesions were only biopsied in case of clinical suspicion of recurrence. The primary endpoint of 1-year clearance rates is short for BCCs, but 5-year follow-up is ongoing and will be reported. To summarize, correctly performed combined curettage and cryosurgery with standardized protocols (videos available in Backman et al5Backman E.J. Polesie S. Berglund S. et al.Curettage vs. cryosurgery for superficial basal cell carcinoma: a prospective, randomised and controlled trial.J Eur Acad Dermatol Venereol. 2022; 36: 1758-1765Crossref Scopus (4) Google Scholar) provided excellent clinical clearance rates with both 1 and 2 freeze-thaw cycles. Self-reported times with oozing wounds were short and patients were generally satisfied with the cosmetic outcome. This investigation increases the evidence for curettage plus cryosurgery, a low-cost and time-saving treatment for BCCs with nodular features. None disclosed. Letter from the Editor: Treatment of basal cell carcinoma with curettage aloneJournal of the American Academy of DermatologyPreviewIn this issue of the Journal of the American Academy of Dermatology, Backman et al discuss curettage combined with cryotherapy for the treatment of basal cell carcinoma (BCC). They compared clearance rates at 1 year for curettage and cryosurgery (halo thaw time ≥ 60 seconds) in 1 vs 2 freeze–thaw cycles for nonfacial BCCs with clinically nodular features. Both produced excellent clearance rates with no statistically significant difference between 1 or 2 cycles. Full-Text PDF